Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Sunday, July 30, 2006

Memorable patients: part four

I didn't know her name until it was over, much too late. What I knew was she was thirteen and that on this winter day someone in her family had been pulling her behind their car, on a sled. No doubt laughing and looking in the rear-view mirror, the person driving had whipsawed around a corner, and the young girl -- probably screaming (fear? delight?) -- held onto the sled as it careened off the road and into the side of a concrete culvert. The girl took the blow in the middle of her right side. Reportedly, as they helped her up, crying, she fainted. The family member did what a family member who'd pull someone behind a car on a sled would do: took her home and laid her on the couch. About forty-five minutes after that, when she was unarousable, 911 was called. Half an hour after that, she arrived in the ER, in full cardiac arrest, which was also the way the medics had found her.

There was still electrical activity in her heart. Her pupils were dilated, we couldn't measure any blood pressure. But she was thirteen. Several IVs were started, massive fluids infused, and she started to produce a pulse. Her belly was greatly swollen. We got her to the OR before the O-negative blood arrived (it can be given fairly safely to anyone, regardless of blood type), and continued the resuscitation until it seemed possible to anesthetize her and cut her open.

Blood had filled her abdomen. I scooped it out, mopped it out, suctioned it out. Her liver looked as if someone had inserted an M-80 firecracker into it and lit it off. As soon as I'd gotten in -- you can slash inside pretty rapidly when you need to, making a nick in the upper abdomen, inserting a couple of fingers, lifting up hard, sticking the scalpel between the fingers and zipping straight south in one motion -- I'd put a clamp across her abdominal aorta, just below the diaphragm, to limit the amount of blood that could enter and leak out; plus, it helps maintain blood pressure to the head and heart. I stuffed a few packs into the crater of her liver and pressed on them. Had I gotten to the point of trying to repair the damage, it would have been hard as hell.

Instead, my aim was just to control bleeding, enough to give the assembled group of nurses and anesthesia folk time to catch up on her fluid needs, push in pint after pint of blood; try to get her stable enough to see what would happen. Clamp on the aorta: done. Pack the liver: done. Pringle maneuver: did it. For a while, we observed a sustained blood pressure, so I made ready to see what I could do about the wreckage. Then her EKG complexes started to widen. Eventually, they became slower and slower, flattening out, resistant to all the drugs that were tried. I took turns with the assistant compressing her chest. And finally, when it was beyond obvious, we stopped. In-field CPR for half an hour before arrival, plus who knows how long in arrest before the medics arrived: too little, too late.

When you close an abdomen after a failed rescue, the OR is silent. No beeps from monitors, no sighs of the ventilator, no small talk. You use a large suture on a giant needle, taking big bites of tissue, making it quick. On a thirteen year old, with a baby's beautiful skin, healthy tissues giving more resistance to the needle than usual, perfect organs disappearing from view, you are sewing through tears. You feel the loss as if it were your own.

I went alone to the family area. I've done that walk a few times: If the earth were to open up and swallow me at that point, it'd be ok with me. The mom was there, maybe a few others. Seeing the look on my face, she stepped toward me, hand in a fist, pressed against her mouth. "I'm sorry," I said. "I couldn't save her." Without a pause, the mom began beating me on the chest, with both fists, hard, yelling and moaning, crying, "What do you mean you couldn't save her? Why? Why? How could you not?" "I'm so sorry," I said, again, finding none but the predictable words. "We tried everything, but there was too much damage." Letting her beat away without raising my hands, forcing back the obvious statement: had she been brought in immediately we'd have had a chance. "Oh my God. How could you not save her? Oh my God, oh my God, oh Amy, oh Amy."

54 comments:

This one gave me goosebumps! That must have hurt you. Was she the first one lost in your OR? How did you deal with that?

This will sound strange--I lost a patient once. She had terminal cancer and was on geropsych. It was simply her time, and there was nothing I could do, because of a DNR. I remember the frustration, wanting to do CPR, knowing I shouldn't (couldn't), and at the same time, knowing it would do no good. The only result would have been chest trauma had I done that. But still...

willow-esque: it's pretty rare, as you know, to lose a patient in the OR, and it's especially painful. It's implicit that if a patient's there, there's a chance. On the other hand, it's virtually exclusively ones who start with the odds stacked high against them -- trauma victims mainly, or people about whom you and the relevant family and patient have said a 1% chance is better than no chance. Still, it feels like failure. In this case, what I remember vividly -- and it happened at least 15 years ago -- is the feeling of being beat upon by the mom. It can almost make my chest hurt.

There are -- he says, hawkingly -- several, descriptions of losing patients, both in the OR and out, in my book, amply linked elsewhere in this blog.

The chief of surgery at Tulane in the 1960s used to say a surgeon was a physician who could operate.Sometimes a surgeon is a physician who can operate and be able to write in such a way that a reader-medical and otherwise-can share the drama,excitement and pathos that transpires during another day at the office for a physician who does surgery.

I have been there in another life in another country at war - you brought it all back in a sudden rush - I thought I had forgotten but remember again why it is so important to feel this way.When this stuff no longer affects us in this primal , visceral way - time to retire , quit or change career - thank you.

Well, now it's me: I don't know what to make of the question...I can't tell if you're criticizing the hawking, or my concern about hawking. In any case, here's how I feel about it: I have a blog, and I wrote a book. The two are separate but not entirely unrelated in that I want people to read both. So, when relevant, I'm inclined to mention my book in some of my posts. On the other hand, I feel slightly ambivalent about it, because I don't want readers of this blog to see it just as some sort of wordy PR. So I"ve usually made some slightly embarrassed side comment about hawking, as if to acknowledge that some may see it as crass. And yet.... I like my book and people who read it seem to as well (I'd link to reviews, but I won't). So I do hope this blog will be a pathway to discovering the book. But now that I'm blogging, I'm doing it for its own sake, because I like it. The blog is always unfinished and fluid. The book is done.

Dr. Schwab-Please consider submitting something to Change of Shift next week. I see you already link to Emergiblog, the home to Change of Shift, but Im hosting next week and I'd love to have something from your blog or book because I enjoy them both.Thanks!

Wow, spell-binding! I am thankful there are amazing people such as yourself willing to do such a job with all of the difficulties and heart-aches. Must take a toll on you! *blog hugs* and lots of encouragements! thank you for being a surgeon!

I just read you this evening for the first time. You're a wonderful writer and and even more wonderful Dr. I don't know how you guys do what you do.

Here's is something else I didn't know until recently. Why are all doctors also excellent writers? Is it because of the experiences you have that make the words flow? Or, is there something connected to writing and practicing medicine?

The latter doesn't really seem possible, as one really has nothing to do with the other.

Cathy: thanks for your kind words. I think the docs who are good writers are writing, and the ones that aren't, aren't. I know a few docs who might have slept through English 101. (In my case, my freshman English class in college made a huge difference: we wrote three essays a week, and the prof printed up parts and distributed them to the class: in small seminars we tore each other apart. I think it helped.) But I do agree with your premise that most docs have seen plenty that makes for good subject material. I've got more in me, I know that much.

I read your book long before happening to find your blog. Your apologies for mentioning that you wrote a book are unecessary. Those who enjoy these stories would love your book, and you are doing them a service by making them aware it exists. It played a small yet integral part in my decision to pursue a career in medicine and potentially general surgery. Thanks for the insight into your life!

But.....the family was pulling her behind the car and when she was unconscious took her home and laid her on the couch for close to an hour before calling 911 and then blame you for her death. Good grief.

I'm not surprised by their reaction. For most people, it's a virtual impossibility to accept that they had killed their own daughter. Someone must be blamed, and their grief prevents them from blaming themselves.

Brings back memories. It always feels the same, even after decades, doesn't it? I comfort myself with the thought that the only way to make it stop hurting would be to forget them. I would rather keep hurting, if that is the price remembering them exacts.

My first child was stillborn - a totally unexpected event, and utterly devastating. However, I only had to go through that once. I've often thought of those ob/gyns (and the delivery room nurses) who deal with high-risk pregnancies, and who have had numerous babies die. It must be terrible.

Oh geez... I can't imagine the guilt and the loss you must feel when you find that all of your skill, all of your technology, when everything you know is simply not enough... But to know that all of it could have been prevented by the people who loved that child... To know that it was senseless stupidity and a complete disregard for that child's safety that brought her to you...

...and to have those very people be angry with you for not being able to fix their mistake, their incompetence as parents...

I don't know how you guys do it, day in and day out and still maintain the compassion that you so obviously have for the human race. You are a better man than I, sir... A better man than most of us...

Badriab: in the context of an emergency such as this, it's done essentially blind, by feel: reaching in with one hand above the stomach at the g-e junction, feeling the aorta behind the esophagus, and guiding a large vascular clamp across both. If and when the situation becomes semi-stable, there may be the opportunity to place it more carefully.

I should add this: in an emergency, the first thing to do is reach in and compress the aorta between your thumb and fingers; then, if it takes a while to get the right clamps, you can compress it with a "stick sponge." There are also instruments with a very broad and flat distal end, for placing over the aorta and pressing down on it.

So glad to have found your blog. I am going to devour every word of it. I work in Trauma Research at the R. A. Cowley Shock Trauma Center in Baltimore, Maryland. While I have no formal medical training (I have a public health degree so far) I am infinitely interested in everything I see going on around me and am constantly trying to learn as much as I can about what ails every patient that comes through our doors.

I have seen several scenarios play out just like the one you just described - the 15 year old boy living in the inner city who had his entire life ahead of him with honor roll and marching band...his promising life taken from him in a case of mistaken identity by a local drug dealer and four fatal gunshots (the boy was still talking and begging for reassurance of life as he was lying in our trauma bay where the attending surgeon was trying her damndest to keep him alive through two cardiac arrests and make good on her promise)...the young woman who was well known and much loved at the high school she worked at helping underpriveledged kids get into internships, who had her throat randomly slashed as she waited in line with her boyfriend at a convenience store. Unfathomable and horrific.

My job is currently working on studies dealing with coagulopathy and traumatic brain injury in addition to two drug studies. I love my job and am dying to know more about medicine.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.